Addressing the social inequities of vaccination: an imperative to close the gap
Authors: Mathew D Marques, Meru Sheel
Journal: The Lancet Global Health (2023)

The COVID-19 pandemic has opened fissures along social, political, economic, and health domains. In doing so, the pandemic uncovered the inequities relating to access and acceptance of vaccines within and across countries. In The Lancet Global Health, Nicole Bergen and colleagues1Bergen N Kirkby K Fuertes CV et al.Global state of education-related inequality in COVID-19 vaccine coverage, structural barriers, vaccine hesitancy, and vaccine refusal: findings from the Global COVID-19 Trends and Impact Survey.Lancet Glob Health. 2023; 11: e207-e217Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar use a series of large-scale online cross-sectional global surveys to describe how country-level and individual-level indicators of inequality were associated with both vaccine hesitancy and vaccine refusal among unvaccinated people. Leveraging the largest global health survey to date over approximately 2 years (April 23, 2020, to June 25, 2022) across 90 countries, at first glimpse the paper provides a time-sensitive approach to monitoring vaccine demand and uptake consistent with WHO priorities.2WHOStrategy to achieve global COVID-19 vaccination by mid-2022.https://www.who.int/publications/m/item/strategy-to-achieve-global-covid-19-vaccination-by-mid-2022Date: Oct 6, 2021Date accessed: December 6, 2022Google Scholar Bergen and colleagues highlight some practical issues (eg, structural barriers and income inequality), alongside education level, to provide a baseline for monitoring across country-level and individual-level indicators of inequality, but did not explain the implications of their findings. Prominent findings—such as that the most educated people had higher self-reported receipt of a COVID-19 vaccine than did the least educated people globally, or that higher prevalence of vaccine hesitancy was associated with lower education, whereas higher prevalence of vaccine refusal was associated with higher education—are at times lost within an increasingly complex narrative and unexplained findings. These effects were qualified across low-income countries (LICs), lower-middle-income countries (LMICs), upper-middle-income countries (UMICs), and high-income countries (HICs). For instance, in LICs and LMICs relative to UMICs and HICs, there were more reported structural barriers to vaccination and vaccination hesitancy was higher among the most educated people, despite there being overall low vaccination refusal. By contrast, in HICs, structural barriers were lower and vaccination refusal was higher relative to LICs and LMICs, with refusal highest and hesitancy lowest for the most educated people. Although the findings of this study offer novel insight into education-related inequalities in relation to COVID-19 vaccination, the results are unsurprising given the well-established literature surrounding the role of education among caregivers for uptake of childhood vaccination. These data can provide insights into the mechanisms and drivers of COVID-19 vaccination. A multi-round cross-sectional study of children in India over 24 years found that social disadvantage, including income inequality and lower maternal education, was associated with higher zero-dose status.3Johri M Rajpal S Subramanian SV Progress in reaching unvaccinated (zero-dose) children in India, 1992-2016: a multilevel, geospatial analysis of repeated cross-sectional surveys.Lancet Glob Health. 2021; 9: e1697-e1706Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar In Bangladesh, increases in measles vaccination coverage was associated with higher parental education (particularly maternal).4WHORegional Office for South-East Asia. Trend and factors affecting zero-vaccination status of children for measles-containing vaccine in India: analysis from two recent demographic and health surveys.https://apps.who.int/iris/handle/10665/345257Date: 2021Date accessed: December 6, 2022Google Scholar Self-reported level of education might be associated with vaccination decisions, as a proxy for personal health literacy. Crucially, health literacy might be as important for prevention of communicable diseases as it is for non-communicable diseases,5Paakkari L Okan O COVID-19: health literacy is an underestimated problem.Lancet Public Health. 2020; 5: e249-e250Summary Full Text Full Text PDF PubMed Scopus (393) Google Scholar given the dynamic environment we live in, which can filled with both information and misinformation.6The Lancet Infectious DiseasesThe COVID-19 infodemic.Lancet Infect Dis. 2020; 20: 875Summary Full Text Full Text PDF PubMed Scopus (198) Google Scholar However, this is not to say it should be exclusively incumbent on the individual to make appropriate health decisions, as there should be an emphasis on authorities and governments to communicate in ways that are understood by various sections of society, especially when inequities might exist. This responsibility also extends to HICs, including the USA, where low education is associated with reduced COVID-19 vaccination uptake.7Khairat S Zou B Adler-Milstein J Factors and reasons associated with low COVID-19 vaccine uptake among highly hesitant communities in the US.Am J Infect Control. 2022; 50: 262-267Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar The transmission, receipt, consideration, and action on health information is a social and behavioural process. Understanding barriers and enablers of vaccine uptake is critical. The recently launched tool to understand and evaluate the Behavioural and Social Drivers (BeSD) of vaccination8WHOUnderstanding the behavioural and social drivers of vaccine uptake WHO position paper—May 2022.https://www.who.int/publications-detail-redirect/who-wer9720-209-224Date: May 20, 2022Date accessed: December 6, 2022Google Scholar proposes a measurable framework across four domains that lead to the uptake of recommended vaccinations: Thinking and Feeling alongside Social Processes, lead to Motivation, which in turn predicts Vaccination and is moderated by Practical Issues. Online surveys, although informative, continue to raise the need for primary data collection and validation of findings to facilitate a better understanding of the drivers of vaccination intention and uptake. Such surveys can also help shift the traditional focus on individual determinants and hesitancy, at the expense of social determinants of vaccination, such as inequities in education and access.9Attwell K Hannah A Leask J COVID-19: talk of 'vaccine hesitancy' lets governments off the hook.Nature. 2022; 602: 574-577Crossref PubMed Scopus (14) Google Scholar For example, a study in Indonesia used the BeSD framework and identified high support for immunisation and trust in health-care providers, despite low levels of uptake, suggesting ongoing monitoring and context-specific recommendations were needed, such as building social and peer encouragement for immunisation.10WHOFactors affecting childhood immunization in Indonesia.https://www.who.int/indonesia/news/detail/13-02-2022-factors-affecting-childhood-immunization-in-indonesiaDate: Feb 13, 2022Date accessed: December 13, 2022Google Scholar Inequities in social processes, such as education, reiterate the need to address intergenerational and societal inequities, such as access to education. These inequities highlight the importance of working across sectors, including education and social welfare, for longer-term improvement in health outcomes of individuals. There is a paucity of studies examining the direct relationship between changes in education policies and preventive health outcomes, such as vaccine uptake, suggesting more research is needed with validated measures. In the meantime, targeted educational programmes, communication, and efforts to improve health literacy are needed to improve vaccine uptake in the more immediate to medium term. Such measures are likely to have an ongoing greater role as adult vaccination programmes (eg, for COVID-19) continue to be expanded, or during outbreak settings (eg, Ebola or mpox [formerly known as monkeypox]), where acute efforts are needed to drive the rapid rollout of immunisation programmes. I declare no competing interests. Global state of education-related inequality in COVID-19 vaccine coverage, structural barriers, vaccine hesitancy, and vaccine refusal: findings from the Global COVID-19 Trends and Impact SurveyThis study serves as a baseline for continued inequality monitoring and could help to inform targeted actions for the equitable uptake of vaccines. Full-Text PDF Open Access